Can Low Back Pain Be Managed Without Surgery or Drugs?

Laird Harrison

Treating Nonspecific Low Back Pain

David Hanscom, MD, was just completing his training as a spine surgeon at Twin Cities Scoliosis Center in Minneapolis, Minnesota, in 1985, when his own horrible spine pain overtook him. "I was spiraling down," he says. "Back pain, neck pain—I didn't know how it hit me."

Dr Hanscom had surgery for a ruptured disc, but it took him until 2002 to figure out that he could only escape the pain by controlling his stress and reprogramming his thoughts. Now working at Swedish Neuroscience Specialists in Seattle, Washington, Dr Hanscom offers a range of such therapies to his patients with chronic spine pain and prides himself on helping them avoid surgery altogether.

Nonspecific low back pain—that is, back pain without a specific diagnosis—has become a major public health problem worldwide, with a lifetime prevalence as high as 84%. And the prevalence of chronic low back pain is about 23%.^[1]

Evidence is mounting for the efficacy of treating nonspecific chronic pain not with surgery or narcotic medications, but with therapies drawn from psychology and meditation. The research supporting cognitive-behavioral therapy (CBT) and mindfulness-based stress reduction (MBSR) is particularly robust.^[2]

But these approaches, particularly CBT, remain out of reach for many of the people who need them, says epidemiologist Dan Cherkin, PhD, MS, senior scientific investigator at the Group Health Research Institute in Seattle.

For one thing, not many psychologists are trained to offer CBT for pain management, Dr Cherkin notes.

For another, "a lot of the things that have been found effective for nonsurgical pain are not covered by insurance and not widely available," he says. "It's a wide social problem, and a training and reimbursement issue, that prevents patients from trying things that are shown to be effective."

Reducing Pain by Changing Thoughts

Progress may depend on a more widespread understanding that the division between mind and body is artificial, says Dr Cherkin. Although its roots go back at least as far as the Greek Stoic philosopher Epictetus (55-135 AD), who stressed the importance of self-knowledge, CBT was developed by psychologists and psychiatrists in the mid-20th century as a treatment for mental health disorders.^[2]Unlike many psychotherapies, CBT is guided by empirical research and focuses on solving problems in the present rather than uncovering trauma in the past.^[2]

The researchers who developed CBT began with the premise that people can change unwelcome feelings and behavior by countering distorted thoughts behind them.

This process has a biochemical dimension. The emotional stress of pain may cause the release of adrenalin and cortisol, which increases conductivity of nerves, increasing the pain, Dr Hanscom explains. Over time, the nervous system may also adapt in such a way that the pain persists even after any physical trauma is healed.

"Anxiety is simply a chemical response to sensory inputs," Dr Hanscom says. "The problem with thoughts, compared with the other stimuli, is that you can't escape your thoughts. The harder you try to fight them, the worse it gets."

With CBT, people can learn strategies for putting their fears into perspective. The therapy takes multiple forms, including one-on-one conversations with trained therapists, group treatments, reading, and writing.^[3] Multiple studies have shown CBT to be effective in reducing back pain.^[2]

In contrast, the origins of MBSR lie in Buddhist meditation and yoga. Molecular biologist Jon Kabbat-Zin, PhD, developed the first class in MBSR at the Massachusetts Medical Center in Worcester, Massachusetts, in 1979. In MBSR, the practitioner seeks to increase awareness and acceptance of such experiences as discomfort and negative emotions.^[4] Although MBSR is less well-studied for back pain than is CBT, the research so far suggests that it may also be effective.^[2]

Studies using MRI suggest that CBT and MBSR cause some brain remodeling.^[5,6]

Two Approaches to Pain Management

In recent years, therapists have tried melding the two approaches, in what has been the "third wave" of CBT techniques.^[3]

To see whether one modality works better than the other, Dr Cherkin and colleagues recruited patients with at least 3 months of chronic back pain from Group Health, a large healthcare system in Washington State, for a randomized clinical trial.^[2] The investigators excluded people with specific diagnoses—those with ruptured discs, spinal stenosis, fractures, or tumors represent different patient populations and may not be as responsive to mind/body therapies—and randomly assigned 113 persons to receive usual care, 116 to receive MBSR, and 113 to receive CBT. Collectively, these participants had had back pain for a mean of 7.3 years.

All participants received the medical care they would otherwise have received.^[2] Those in the usual-care group were allowed to seek whatever treatment they wished.

The MSRB and CBT groups both met for 2 hours of therapy per week for 8 weeks.^[2] Only 59 people in the MBSR group and 64 people in the CBT group were motivated enough to attend at least six sessions. The MBSR program included an optional 6-hour additional retreat, which 30 people attended.

Participants in both the experimental groups received workbooks, motivational audio compact discs, and instructions for home practice.^[2]

Eight instructors with 5-29 years of experience administered MBSR in the study. Four licensed PhD-level psychologists who were experienced in group and individual CBT for chronic pain administered CBT.^[2]

After 26 weeks, both the CBT and MBSR groups showed more improvement than the usual-care group in measures of pain, disability, and depression.^[2] For example, on the Roland Morris Disability Questionnaire, 60.5% of participants in the MBSR group experienced meaningful improvement, which was statistically similar to the 57.7% of the CBT group but greater than the 44.1% of the usual-care group who experienced improvement.

The results for improvement in pain bothersomeness were similar: 43.6% for MBSR, 44.9% for CBT, and 26.6% for usual care.^[2] At 52 weeks, CBT was no longer superior to usual care, whereas MBSR still was.

The researchers are now trying to figure out whether CBT and MBSR work by the same mechanism. "I'm not sure there are a lot of differences between treatments that appear roughly similar to patients," says Dr Cherkin.

One Surgeon's 5-Step Process

Ideally, a clinician could offer someone with chronic back pain a range of treatments, including yoga, acupuncture, massage, spinal manipulation, and structured exercise programs, as well as MBSR and CBT, Dr Cherkin says.

But he cautions that offering psychosocial therapies to patients referred for surgery could be problematic if patients feel they are being told, "It's all in your head." Dr Cherkin says he is not aware of studies in which mind/body therapies were used in patients who had prior spinal surgery but who were still in pain.

Dr Hanscom can share his own experience with his patients. He addressed his stress first by following lessons in the book Feeling Good: The New Mood Therapy, by psychiatrist David D. Burns, MD.^[7] As the book instructed, Dr Hanscom wrote down his negative thoughts and then categorized them. Gradually, his anxiety diminished.

But recovery wasn't as simple as doing a few writing exercises. "I improved over about 6 weeks and stalled," Dr Hanscom recalls. "I was forced to address my anger issues, and that is when I really noticed a dramatic decrease in my symptoms."

Now when patients come to him with chronic back pain, he investigates to find out whether they have a precise structural indication for surgery, such as a bone spur causing sciatica. If they do, he performs surgery.

But absent such a structural cause of pain, he offers patients a set of resources they can use for getting out of pain:

• Learn about the causes of your chronic pain;
• Do expressive writing;
• Meditate;
• Get a good night's sleep via a technique such as sleep hygiene—or sometimes medication; and
• Learn not to share your pain.

"Talking about their pain too much will reinforce 'unpleasant circuits' that develop in the patients' brains wherever their attention is focused," Dr Hanscom says.

Dr Hanscom has codified this approach in a book, Back in Control: A Spine Surgeon's Roadmap Out of Chronic Pain. Using this approach, Dr Hanscom has found that he and his colleagues were often able to reduce patients' use of narcotics—or even wean them off altogether.

At least 60 of Dr Hanscom's patients, who were scheduled for spine surgery, canceled their procedures after trying his recommendations. Dr Hanscom is preparing a paper discussing these results.

But he doesn't pretend that he has an easy solution to offer everyone with back or other forms of pain. Pain still crops up in Dr Hanscom's own life—most recently, in the form of an arthritic knee. So far, he has avoided replacing the joint, but it has taken a lot of concentration. "I am still on a learning curve," he says.